[Endotracheal aspiration: a "banal" maneuver or a targeted therapeutic intervention?].
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Critical Care↗
Biomedical subjects
F Procaccio
Publications and source records attributed to F Procaccio.
Continuous EEG and ICP monitoring as a guide to the administration of althesin sedation in severe head injury.
The effects of 142 intravenous boluses of althesin (0.05 ml/kg) on cerebral perfusion pressure (CPP) were studied in twelve head injured comatose patients. The data were divided into those where the mean pre-bolus intracranial pressure (ICP) was above or below 20 mmHg and then subdivided into those where the minimum pre-bolus voltage of the cerebral function monitor (CFM) was above or below 5 microV (representing marked reduction in cortical electrical activity). The pre-bolus ICP influenced the extent of the fall in ICP and thus the direction of the resulting change in CPP. A mean reduction in CPP was observed in both groups in which ICP was below 20 mmHg irrespective of the CFM voltage. In the subgroups with high ICP, CPP increased when CFM was not depressed and fell when CFM was below 5 microV. The effects of individual boluses varied within and between the subgroups and, occasionally, severe and unpredictable hypotension occurred. If althesin administration had been restricted to the high CFM and high ICP group, 90% of the episodes of reduced CPP would have been avoided. In fact, when cortical electrical activity is already severely depressed, further administration of hypnotic anaesthetic agents produces only small reductions in ICP and usually a fall in CPP. These findings suggest that the minimum voltage of the CFM trace is a clinically useful guide to the administration of intravenous anaesthetic agents and offers a relevant prediction of their effects on CPP.
Adolescent↗
Clinical pharmacological and therapeutic considerations in general intensive care. A review.
The application of clinical pharmacological concepts and therapeutic standards in intensive care settings presents particularly difficult problems due to the lack of adequately controlled background information and the highly variable and rapidly evolving clinical conditions where drugs must be administered and their impact evaluated. In this review, an attempt has been made to discuss the available knowledge within the framework of a problem-oriented approach, which appears to provide a more clinically useful insight than a drug-centred review. Following a brief discussion of the scanty data and the most interesting models to which reference can be made from a pharmacokinetic point of view (the burn patient being taken as an example), the review concentrates on the main general intervention strategies in intensive care patients. These are based mainly on non-pharmacological measures (correction of fluid and electrolyte balance, total parenteral nutrition, enteral nutrition, oxygenation and ventilatory management) and are discussed with respect to the specific challenge they present in various clinical conditions and organ failure situations. In addition, 4 major selected clinical conditions where general management criteria and careful use of prophylactic and therapeutic drug treatments must interact to cope with the variety of presentations and problems are reviewed. These include: acute cerebral damage; anti-infective prophylaxis and therapy; cardiovascular emergencies; and problems of haemostasis. Each problem is analysed in such a way as to frame the pharmacological intervention in its broader context of the underlying (established or hypothesised) pathophysiology, with special attention being paid to those methodological issues which allow an appreciation of the degree of reliability of the data and the recommendations which appear to be practiced (often haphazardly) in intensive care units. The thorough review of the published literature provided (up to mid-1986) clearly shows that in this field the quality of randomised controlled and epidemiological studies is rather unsatisfactory. It would be highly beneficial to research and to clinical care if larger multicentric protocols and prospective epidemiological comparative investigations could be carried out to investigate more timely and adequately the variables which determine drug action, and the final outcome in the many subgroups of patients which must be considered in a proper stratification of intensive care unit populations.
Critical Care↗
Viscero-somatic and viscero-visceral reflexes in brain death.
Little is known about spinal visceral reflexes in brain-dead man, although they have been described in experimental animals. In 1983, 25 brain-dead individuals were observed during donor nephrectomy. It was confirmed that some of these donors, without higher centre modulation and not under significant pharmacological influence, had viscero-somatic motor reflexes and viscero-visceral cardiovascular reflexes.
Adolescent↗
Cerebral electrical activity influences the effects of etomidate on cerebral perfusion pressure in traumatic coma.
The effects of 124 boluses of etomidate 0.2 mg kg-1 i.v. on intracranial pressure (ICP), mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) were studied in eight patients with severe head injury (Glasgow coma score less than 8). The data were divided into two groups based on the minimum voltage of the cerebral function monitor (CFM) recording before the bolus. In group A this was less than 5 microV (representing profound cortical electrical depression), while in group B the minimum voltage was greater than 5 microV. The mean decrease in ICP following etomidate was significantly greater in group B (mean +/- SEM: -8.6 +/- 0.7 mm Hg) than in group A (-3.8 +/- 0.6 mm Hg) (P less than 0.0001). The decrease in arterial pressure was similar in both groups. Consequently, there was a small mean increase in CPP in group B (2.2 +/- 0.9 mm Hg), whereas in group A CPP decreased (-4.7 +/- 1.5 mm Hg) (P less than 0.001). There was a strong correlation between the decreases in ICP and MAP in group A (r = 0.70, P less than 0.01), but not in group B (r = 0.05). Thus, when cortical electrical activity was already maximally suppressed, further administration of an i.v. anaesthetic agent produced only relatively small decreases in ICP, largely as a passive response to decreases in MAP. CPP was therefore usually reduced. Conversely, in the absence of such depression larger decreases in ICP, unrelated to hypotension, occurred and these were usually associated with increases in CPP. However, even under these circumstances, potentially dangerous decreases in CPP may be seen.
Adolescent↗
Correlations between anti-dsDNA antibodies, complement levels and clinical course in SLE patients treated with steroid pulse therapy.
In patients with SLE dsDNA binding activity, C3 and C4 levels are correlated with the clinical course of the nephritis. In fact the study of these serological parameters has a prognostic value in patients treated with methylprednisolone pulse therapy. This treatment can rapidly normalize an acute phase.
Adolescent↗
Deaths with acute cerebral lesion and heart-beating potential organ donors in the Veneto region.
BACKGROUND: The study was aimed at describing the clinical characteristics of dead patients with acute cerebral lesion and analyzing reasons of the shortage of heart-beating potential organ donors in the Intensive Care Units (ICUs) in the Veneto Region. METHODS: Data have been prospectively recorded in 23 ICUs over six months for deceased patients with acute cerebral lesion (clinical data, death diagnosis) and for any potential organ donor (medical suitability, family interview, organ retrieval). RESULTS: In the ICUs of the Veneto Region in 1998 deceased patients with acute cerebral lesion were 187 per million population (p.m.p.); 317 cases have been studied. Median age was 64 years (range 7-93). Heart-beating death was legally confirmed only in 98/317 cases (31%) against a clinical diagnosis of brain death in 203/317 (64%). Only 82/317 (26%) were considered eligible donors and 48/317 (15%) became real donors (22.8 p.m.p.). Among the remaining 235 cadavers, 105 were over 70 years old. In the group of 130 under 70 years absolute contraindications were present only in 30 and problematical clinical situations were reported in 100. CONCLUSIONS: The number of deaths with acute cerebral lesion represents a sensible index and a key factor for evaluating the potential organ donor pool in small regions and in the single intensive care unit. Collected data demonstrate that in the Veneto Region the efficiency of solid organ retrieval can be improved and that organ donor shortage may depend, beyond family refusal, on clinical and cultural factors that hamper stabilized heart-beating deaths. Most potential donors with age over 70 or problematical clinical situations are preventively excluded by ICUs physicians. To improve organ donation all the patients who die in spite of neuro-intensive treatment should be prevented from circulatory arrest to permit legal declaration of death. Thus more potential organ donors without absolute contraindications could be recovered and time would exist for discussing any problematical situation with experts in organ procurement, particularly in respect to existing urgencies in the waiting list.
Adolescent↗